Leak Adjustment Application

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Please correct the fields below:

Please correct the field(s) marked in red below:

This applications is to be used to request a leak adjustment if you are a Roswell Water Utility customer and have had a leak repaired within the last 45 calendar days. Receipts related to the repair are required.

If you have any questions, please contact the Roswell Financial Services Division at fsd@roswellgov.com or 770-641-3759.

Account Information

*

Account Information

Account Number:

Customer ID:

Name on Account:

Service Address:

Phone:ext.

Email:

Description of leak and what was repaired:

Date the repair was made:

Receipts

Receipts

Please upload receipts related to the repair.

Click button for uploading file

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Maximum size allowed: 5 MB

Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Receipts

Click button for uploading file

Clear

Maximum size allowed: 5 MB

Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Receipts

Click button for uploading file

Clear

Maximum size allowed: 5 MB

Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Additional receipts can be emailed to fsd@roswellgov.com.

Was the leak repaired within the last 45 calendar days?

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Was the leak repaired within the last 45 calendar days?

Yes

No (I understand my adjustment request will not be considered)

Do you have receipts to include with this application?

*

Do you have receipts to include with this application?

Yes

No (I understand my adjustment request will not be considered)

*

Signature (Please type your full name in lieu of your signature):

Date:

To receive a copy of your submission, please fill out your email address below and submit.
Email Address